Tylenol or acetaminophen? TUMS or calcium carbonate? In the course of daily work, do clinicians more often refer to a medication by its brand name or generic name?

A new study that appears in the Journal of General Internal Medicine measures just that by sifting through more than a million pages (in text form) to internal medicine residents. I chatted with the lead author, Stanford cardiology fellow David Ouyang, MD, about the results and implications.

Why is it significant whether a drug is referred to by its brand name or generic name?

A big recurrent issue in health care is cost. When we address a drug by its brand name, research has suggested that the physician is more likely to use the brand name drug, even though it’s functionally the same as the generic. This was why, in part, drug companies pay drug reps — to promote familiarity with a drug and its brand name. And because brand names are more expensive, they're more likely to have a significant burden on the health care system.

The second main issue is a learning issue. When I was a medical student, being in the hospital was one of the first places that we learned about medications. Many people would call it the hidden curriculum of medicine... there’s a lot of hidden curriculum in how we choose and name the medications.

What has been done to discourage clinicians from referring to drugs by their brand names?

Style guidelines for JAMA, the Association of American Medical Colleges and others recommend using generic names in communication, writing and at conferences. My sense is that there’s a lot of variation across institutions, but many institutions have policies to limit the use of brand names and prevent pharmaceutical influence. To prevent the perception of having bias or endorsing certain medications, many doctors use the generic name of most medications.

Most states have laws where unless either the patient or the physician says they don’t want it, then most pharmacies are able to substitute the generic medication for a brand name prescription.

Tell me about your approach to this study.

Bias or variation in practice is something that’s fairly hard to measure. If you surveyed physicians, I imagine most would say, ‘Oh, I almost uniformly only use generic names.’ Or ‘I would never tell the brand name to a patient if it’s not indicated in that circumstance.’

We took a big data approach, using a very novel data set: the direct text communication between providers in the hospital. Any time something urgent happens in the hospital, whether it’s a nurse paging a doctor or a physician paging a consultant, it’s often communicated via text page.

Because we actually analyzed a million text pages that were sent to the medicine residents at Stanford, we can get a sense of how frequently medication names were used and what that ratio looks like in comparison to the generic name.

What were the results?

There was a big variation in when and how people used brand names and generic names.

You’d think that people would use a generic name more often for common drugs, and a brand name for medications used more rarely, but our data didn’t show that. Instead, we found that names most frequently used — whether generic or brand — were the ones that were shorter, and easier to remember and to pronounce. In our data, it also looks like nurses are much more likely to use the brand name, and pharmacists are much more restricted to using the generic names.

That’s something that we still want to explore — potentially there might be a little bit more education by pharmacists about the influence of pharmaceutical companies, but it might also just be variation in the culture of different health care providers.

What are the main takeaways?

This is one of the few objective ways that we’re able to take a glimpse into bias in health care, and there’s value in digging deeper into how physicians and how other health care workers interact with one another. In this case, we’re seeing that even though using generic medication names is an ideal that, as medical institutions and medical providers, we strive toward, there’s still a lot of room to improve.

The scenario many of us learned in school is that two X chromosomes make someone female, and an X and a Y chromosome make someone male. These are simplistic ways of thinking about what is scientifically very complex.